Spinal Anaesthesia with Hyperbaric Solutions of Ropivacaine, Levobupivacaine or Bupivacaine in Major Orthopedic Surgery

ORİJİNAL ARAŞTIRMA Spinal Anaesthesia with Hyperbaric Solutions of Ropivacaine, Levobupivacaine or Bupivacaine in Major Orthopedic Surgery Züleyha KAZAK, MD, a N. Meltem MORTIMER, MD, a Sumru ŞEKERCİ, MD, a a Department of Anesthesiology and Reanimation, Ufuk University Faculty of Medicine, Ankara Ge liş Ta ri hi/re ce i ved: 28.04.2009 Ka bul Ta ri hi/ac cep ted: 14.12.2009 This study was presented in 14 th World Congress of Anaestesiologists Cape Town, 03. 03. 2008. Ya zış ma Ad re si/cor res pon den ce: Züleyha KAZAK, MD Ufuk University Faculty of Medicine, Department of Anaesthesiology and Reanimation, Ankara, TÜRKİYE/TURKEY kazakzuleyha@yahoo.com ABS TRACT Objective: The aim of the present study was to compare the reliability, suitability and the side effects of the spinal blocks produced by hyperbaric solutions of levobupivacaine, ropivacaine and bupivacaine in patients undergoing total hip or knee arthroplasty. Material and Methods: Ninety patients, aged 30-75 years with American Society of Anesthesiology (ASA) grade I-III, undergoing total hip and knee arthroplasty were included in the study and randomized into three groups. Spinal anesthesia was performed in all patients; among the study groups in Group HB 3 ml of 0.5% hyperbaric bupivacaine, in Group HR 3 ml of 0.5% hyperbaric ropivacaine and in Group HL 3 ml of 0.5% hyperbaric levobupivacaine were given intrathecally. The same surgeon performed all the operations. Results: The mean duration of complete motor block was longest in Group HB(p=0.047). Onset of sensory block at dermatome level T10 was earliest in Group HL(p<0.002). Regression time of sensory block to dermatome level T10 and L1 was longest in group HB and shortest in group HR (p<0.05). First analgesic requirement was earliest in Group HR. More patients in Group HB required treatment for hypotension. Nausea/vomiting were significantly higher in Group HB (p<0.05). Incidence of hypotension was lowest in Group HR (p<0.001). Conclusion: In 15 mg doses, hyperbaric levobupivacaine showed similar potency and block characteristics to hyperbaric bupivacaine, and the duration of motor and sensory block was the shortest with hyperbaric ropivacaine. Levobupivacaine and ropivacaine had fewer side effects. Key Words: Levobupivacaine; ropivacaine; orthopedics ÖZET Amaç: Bu çalışma, total kalça ya da diz artroplastisi geçiren hastalarda hiperbarik ropivakain, levobupivakain veya bupivakain ile yapılan spinal anestezinin güvenilirliğini, uygunluğunu ve yan etkilerini karşılaştırmak amacıyla yapıldı. Gereç ve Yöntemler: Yaşları 30-75 arasında değişen, Amerikan Anesteziyologlar Derneği (ASA) sınıflamasına göre sınıf I - III arasında olan ve total kalça ya da diz artroplastisi geçirecek 90 hasta çalışmaya alınarak randomize şekilde üç gruba ayrıldılar. Her üç gruba da spinal anestezi uygulandı; çalışmada yer alan gruplardan Grup HB ye 3 ml %0.5 hiperbarik bupivakain, Grup HR ye 3 ml %0.5 hiperbarik ropivakain ve Grup HL ye 3 ml %0.5 hiperbarik levobupivakain intratekal olarak verildi. Bulgular: Motor blok süresi en uzun olan Grup HB idi (p = 0.047). Dermatom T10 düzeyinde en erken duyusal blok ortaya çıkışı Grup HL de gözlendi (p < 0.002). Duyusal bloğun dermatom T10 ve L1 düzeyine gerileme süresinin grup HB de en uzun, grup HR de ise en kısa olduğu görüldü (p < 0.05). İlk olarak analjezik gereksinimi ortaya çıkan grup ise HR grubu oldu. Grup HB de daha fazla sayıda hastanın hipotansiyon açısından tedavi edilmesi gerekti. Bulantı ve kusma da Grup HB de diğer gruplarda olduğundan anlamlı derecede daha fazla idi (p < 0.05). Hipotansiyon insidansının en düşük olduğu grup Grup HR idi (p < 0.001). Sonuç: Eşit dozlarda kullanıldıklarında hiperbarik levobupivakain ile hiperbarik bupivakainin etkinliklerinin ve blok oluşturma özelliklerinin benzer olduğu gözlendi. Diğer yandan, en kısa süreli motor ve duyusal blok hiperbarik ropivakain ile sağlandı. Levobupivakain ve ropivakainin daha az oranda yan etkiye yol açtıkları da saptandı. Anah tar Ke li me ler: Levobupivakain; ropivakain; ortopedi Cop yright 2010 by Tür ki ye Kli nik le ri Turkiye Klinikleri J Med Sci 2010;30(2):731-7 Turkiye Klinikleri J Med Sci 2010;30(2) 731

Kazak ve ark. wo long-ac ting lo cal anest he tics, ro pi va ca i - ne and le vo bu pi va ca i ne, ha ve be en in tro du - ced to cli ni cal use. Le vo bu pi va ca i ne and ro pi va ca i ne are the two lo cal anest he tics that se em to be ra ti o nal al ter na ti ves to bu pi va ca i ne du e to the ir sig ni fi cantly low car di o vas cu lar 1,2 and cen tral ner vo us system 3,4 to xi cities. Com pa ra ti ve cli ni cal stu di es ha ve be en con duc ted with the se two agents for non-obs tet ric 5,6 and obs tet ric epi du ral anest he - si a, 7 brac hi al ple xus bloc k, 8 in fil tra ti on anal ge si a 9 and for spi nal anest he si a. 10 In the pre vi o us stu di es, hyper ba ric so lu ti ons of ro pi va ca i ne and le vo bu pi va ca i ne were used in small do ses for uni la te ral spi nal blocks for out pa ti - ent kne e art hros copy 11 and for in gu i nal her ni a repa ir. 6 Hyper ba ric so lu ti on of ro pi va ca i ne is al so used for uni la te ral block in hig her do ses for lo wer extre mity sur gery 12 and iso ba ric ro pi va ca i ne is used in ma jor ort ho pe dic sur gery in high do ses for bi la - te ral blocks. 13 The ef fects of hyper ba ric forms of the thre e lo cal anest he tic agents bu pi va ca i ne, ro pi va - ca i ne and le vo bu pi va ca i ne in high-do se uni la te ral blocks in ma jor ort ho pe dic sur gery ha ve not be en stu di ed pre vi o usly. In this pros pec ti ve, ran do mi zed cli ni cal study, cli ni cal re li a bi lity and su i ta bi lity of the sen sory and mo tor blocks pro du ced by in trat he cal app li ca ti on of hyper ba ric le vo bu pi va ca i ne, ro pi va ca i ne and bu - pi va ca i ne we re com pa red in pa ti ents un der go ing to tal hip or kne e art hrop lasty. MA TE RI AL AND MET HODS Et hi cal com mit te e ap pro val (16.03.07, 07005) of a Me di cal Scho ol and the writ ten in for med con sents of the pa ti ents we re ob ta i ned for this pros pec ti ve study. Pa ti ents we re ran domly al lo ca ted in to three gro ups by clo sed en ve lo pes. Ni nety adult pa ti ents un der go ing elec ti ve pri mary uni la te ral to tal kne e or hip art hrop lasty, ASA clas si fi ca ti on I-II I, age 30-75 years, he ight >150 cm and we ight 50-100 kg we re inc lu ded in this study. Pa ti ents with con tra - in di ca ti on to spi nal anest he si a, al lergy to ami de lo - cal anest he tics and ble e ding di sor ders we re not inc lu ded. Anesteziyoloji ve Reanimasyon All pa ti ents we re pre me di ca ted with in tra mus - cu lar in jec ti on of 0.5 mg at ro pi ne sulp ha te and 0.05mg /kg mi da zo lam 45 mi nu tes be fo re the ope ra - ti on. As it is ro u ti ne at this ins ti tu ti on, all spi nal blocks we re per for med out si de the ope ra ting ro om (OR) in a pro perly de sig ned block ro om. Fol lo wing ar ri val in the block ro om, in tra ve no us ro u te was estab lis hed with a 20-ga u ge IV can nu la at the dor sum of left hand and 100 mg ra ni ti di ne and 10 mg me toc lop ro mi de we re ad mi nis te red in tra ve no usly. Con ti - nu o us mo ni to ring of electrocardiogram (ECG), nonin va si ve ar te ri al pres su re and pul se oxy metry we re star ted. Af ter in fu sing 500 ml of lac ta ted Rin ger s solu ti on over a pe ri od of 30 mi nu tes, pa ti ents we re pla - ced in la te ral po si ti on on the ef fec ted si de. Du ral punc tu re was per for med with the mid li ne ap pro ach at the L3-4 or L4-5 in ters pa ce using a 25-ga u ge Whi - tac re spi nal ne ed le. Cor rect ne ed le po si ti o ning was con fir med with fre e flow of ce reb ros pi nal flu id, and 3 ml of study drug was in jec ted in trat he cally. The sa - me sur ge on per for med all the ope ra ti ons. Using com pu ter ge ne ra ted se qu en ce of numbers and a se a led en ve lo pe tech ni qu e, pa ti ents we - re ran do mi zed in to thre e gro ups: the first gro up re ce i ved 15 mg of 0.5% hyper ba ric bu pi va ca i ne (gro up HB, n=30), the se cond gro up re ce i ved 15 mg of 0.5% hyper ba ric ro pi va ca i ne (gro up HR, n=30) and the third gro up re ce i ved 15 mg of 0.5% hyper - ba ric le vo bu pi va ca i ne (gro up HL, n=30). The hyper ba ric anest he tic so lu ti ons we re asep ti cally pre pa red im me di a tely be fo re in jec ti on by an anest he si o lo gist who was not in vol ved in furt her pa ti ent ca re. Each of the pa ti ents in the study re ce i ved 3 ml of one of the thre e so lu ti ons: bu pi va ca i ne (Mar ca - i ne: bu pi va ca i ne hydroch lo ri de, As tra Ze ne ca, Sweden) 5 mg ml -1, le vo bu pi va ca i ne (Chi ro ca i ne: le vo bu pi va ca i ne hydroch lo ri de, Ab bot La bo ra to ri - es, UK) 5 mg ml -1, or ro pi va ca i ne (Na ro pin: ro pi va - ca i ne hydroch lo ri de, As tra Ze ne ca, Swe den) 5 mg ml -1, each with 30 mg ml -1 glu co se. Den sity of the lo cal anest he tic so lu ti ons we re (g ml -1 ) 1.00874, 1.00945, 1.00876 for bu pi va ca i ne, le vo bu pi va ca i ne and ro pi va ca i ne, res pec ti vely. 14 Af ter fre e flow of ce reb ros pi nal flu id was obser ved, the ope ning of the spi nal ne ed le was tur ned 732 Turkiye Klinikleri J Med Sci 2010;30(2)

Anesthesiology and Reanimation to ward the de pen dent si de and the pre pa red do se of lo cal anest he tic so lu ti on was in jec ted slowly (injec ti on spe ed: 0.1mL/sec) wit ho ut furt her as pi ra ti on ma ne u vers. The la te ral de cu bi tus po si ti on was ma - in ta i ned for a 15-min pe ri od; af ter wards, pa ti ents we re tur ned su pi ne, trans fer red to the ope ra ting ro - om and the ope ra ti on was ini ti a ted. The de ve lop ment of the block was eva lu a ted and re cor ded using pin prick tests for sen sory block, and mo di fi ed Bro ma ge sca le (0=no mo tor block, 1=ina bi lity to ra i se ex ten ded legs, 2=ina bi - lity to flex kne es, and 3=ina bi lity to flex ank le jo - ints) was used to determine the deg re e of mo tor block at 1 st, 3 rd, 5 th, 10 th, 15 th and 20th mi n- u tes. Ar te ri al blo od pres su re and he art ra te we re re cor ded at 1 st, 3 rd, 5 th, 10 th, 15 th and 20th mi nu tes and at every 20 mi nu te the re af ter un til comp le te reg res si on of the block. The on set and the du ra ti on of sen sory block at der ma to me le vel T10, ma xi mum up per and lo wer spre ad of sen sory block, and the on set (mo di fi ed Bro ma ge sca le 3), in ten sity and du ra ti on of mo tor block we re re cor ded. Af ter the sen sory block was ac hi e ved at der ma to me le - vel T10, sur gery was al lo wed to start. Hypo ten si on (30% or mo re dec re a se in me an ar te ri al blo od pres su re (MAP) from the ba se li ne va lu e) was tre a ted with bo lu ses of IV ep hed ri ne (5 mg) and crystal lo id in fu si on un til the nor mo ten si - ve sta te was ac hi e ved. If hypo ten si on was not res - pon si ve to two con se qu ent bo lu ses of ep hed ri ne and crystal lo id in fu si on a vo lu me ex pan der (Hydrox yethyl starch (HES 130/0.4) in iso to nic so di - um chlo ri de so lu ti on (Vo lu ven, Ger many, 500 ml) was in fu sed. Brady car di a (30% or mo re dec - re a se in he art ra te (HR) from the ba se li ne va lu e) was tre a ted with 0.5 mg IV at ro pi ne. High sen sory block le vel, sen sory block le vel be low der ma to me T10, agi ta ti on, na u se a and vo mi ting we re the ot her un de si red ef fects that we re ob ser ved du ring surgery. The qu a lity of the anest he si a (jud ged by the anest he tist), the qu a lity of musc le re la xa ti on (opi- ni on of the sur ge on) and the deg re e of in tra o pe ra - ti ve com fort (jud ged by the pa ti ent) we re re cor ded as 1: un sa tis fac tory, 2: sa tis fac tory and 3: ex cel lent. Kazak et al The ti me to reg res si on of sen sory block in derma to mes T10 and L1 (by using pin prick test) was re cor ded as well as the he mody na mic pa ra me ters and bi la te ral le vels of both sen sory and mo tor blocks at 0, 20, 40, 60 and 120 mi nu tes af ter the comp le ti on of the sur gery. The pa ti ents we re eva lu a ted for the pre sen ce of na u se a, vo mi ting, fe ver, he a dac he and bac kac he du ring the first 24 ho urs fol lo wing the sur gery. Intra o pe ra ti ve blo od loss and the ti me of first re qu est for anal ge sic me di ca ti on we re al so re cor ded. STA TIS TI CAL ANALY SIS The cal cu la ti on of the re qu i red samp le si ze was ba - sed on me an and stan dard de vi a ti on of comp le te reg res si on of spi nal anest he si a with bu pi va ca i ne, ro pi va ca i ne and le vo bu pi va ca i ne. 10,15 Thirty pa ti - ents per gro up were re qu i red to de tect a 20- min dif fe ren ce in ti me for comp le te reg res si on of spi nal ana est he si a and ex pec ted ef fect si ze to stan dard devi a ti on ra ti o of 0.9, ac cep ting a two-ta i led alpha er - ror of 5% and a be ta er ror of 20%. SPSS For Win dows 11,5 Prog ram was used for sta tis ti cal analy sis. Me an ± stan dard de vi a ti on or me di an [25%- 75% per cen ti les] we re gi ven for nu me ri cal da ta as ap prop ri a te. No mi nal da ta we re pre sen ted by fre qu - en ci es. Da ta dis tri bu ti on was eva lu a ted for nor ma lity by Kol mo go rov Smir nov test. Com pa ri sons of nume ric da ta bet we en the gro ups we re performed by one way ANO VA fol lo wed by Tu key HSD test, or Krus kal Wal lis test fol lo wed by Dunn test. No mi nal da ta among study gro ups we re com pa red using Chisqu a re analy sis. For the eva lu a ti on of he mody na mic pa ra me ters du ring the ope ra ti on, com pa ri sons wit - hin the gro ups we re ma de by analy sis of va ri an ce in re pe a ted me a su re ments with the Tu key HSD test for bet we en gro ups and Bon fer ro ni test for wit hin gro - ups post hoc com pa ri sons. A p va lu e less than 0.05 was con si de red as sta tis ti cally sig ni fi cant. RE SULTS The re was no sta tis ti cally sig ni fi cant difference bet we en the study gro ups for the de mog rap hic pa ra - me ters, age, we ight, he ight, sex, ASA clas si fi ca ti on, ac com pan ying di se a se or use of me di ca ti on (p>0,05) Turkiye Klinikleri J Med Sci 2010;30(2) 733

Kazak ve ark. TABLE 1: Demographic data, operation type (knee/hip), side of the operation (right/left) and duration of the operation. No significant difference. Group HB Group HR Group HL (n=30) (n= 30) (n=30) P Age (year) 65,5±11,5 68,5±7,7 67,3±8,3 0,440 Weight (kg) 76,4±16,1 76,9±19,3 75,8±10,5 0,964 Height (cm) 160,9±8,1 159,0±18,8 162,2±5,1 0,600 Female/Male 17/13 19/11 18/12 0.870 ASA (I-II/III) 26 / 4 27 / 3 23 / 7 0.343 Knee/Hip 16/14 18/12 12/18 0.286 Side (right/left) 12/18 14/16 14/16 0.835 Duration of the 107,2±54,3 106,6±48,3 86,3±34,5 0,146 Operation (min) Group HB: received 15 mg of hyperbaric bupivacaine, Group HR: received 15 mg of hyperbaric ropivacaine, Group HL: received 15 mg of hyperbaric levobupivacaine. Values are represented as mean ±SD or as number. Anesteziyoloji ve Reanimasyon (Tab le 1). The re we re no sta tis ti cally sig ni fi cant diffe ren ces bet we en the gro ups with re gard to ope ra - ti on type (kne e/hip), si de of the ope ra ti on (right/left) or du ra ti on of the sur gery (Tab le 1). The ti me to sen sory block re ac hed T10 and Bro ma ge sca le 3 was sig ni fi cantly lon ger in Gro up HR (p<0.05) (Tab le 2). Ti me for the sen sory block to reg ress to T10 and L1 was the lon gest in Gro up HB and the shor t- est in Gro up HR (Tab le 2). The du ra ti on of mo tor block was the lon gest in Gro up HB, the shor test in Gro up HR and the diffe ren ce was fo und to be sta tis ti cally sig ni fi cant (p<0.05) (Tab le 2). Ti me to first pos to pe ra ti ve anal ge sic re qu i re - ment was si mi lar bet we en the study gro ups (p>0.05) (Tab le 2). Ma xi mal up per sen sory le vel of the block de tec ted by pin prick test on the ope ra - ted si de is pre sen ted in Tab le 3. In each of the thre e gro ups, the re was a sig ni - fi cant dif fe ren ce in he ight of sen sory le vel bet we - en the ope ra ted and no no pe ra ted si des; ho we ver, no dif fe ren ces we re fo und bet we en the thre e gro - ups (Fi gu re 1). The num ber of the pa ti ents with hypo ten si on who re qu i red in tra vas cu lar vo lu me ex pan ders was hig hest in Gro up HB and this result was sta tis ti cally sig ni fi cant (p< 0.001) (Fi gu re 2). Brady car di a neces si ta ting tre at ment was not ob ser ved in any of the pa ti ents (Fi gu re 3). The num ber of the pa ti ents with na u se a or vo - mi ting was hig hest in Gro up HB, and this was fo - und to be sta tis ti cally sig ni fi cant (p< 0.001). The re we re no se ri o us pos to pe ra ti ve comp li - ca ti ons or post du ral punc tu re he a dac he in the pati ents. Ef fi ci ency and qu a lity of the anest he si a, ea se of the ma ni pu la ti on and pa ti ent sa tis fac ti on we re si mi lar bet we en the gro ups. DIS CUS SI ON In this study, cli ni cal and anest he tic fe a tu res and si de ef fects of hyper ba ric so lu ti ons of le vo bu pi va - TABLE 2: Characteristics of motor and sensory block with the three medications. range for maximal upper spread Group HB (n=30) Group HR (n=30) Group HL (n=30) P Sensory onset time(t10) (min) 4,5±2,1 6,2±2,4* 5,6±4,4 0.009 Onset of motor block (min) 5,1±2,5 5,8±2,7* 4,8±2,6 0.029 Time to T10 regression (min) 138,6±28,6 122,6±10,9** 135,4±16,6 0,007 Time to L1 regression (min) 172,4±33,5 143,5±14,3** 151,3±25,5 <0,001 Duration of motor block (min) 166,3±40,8 128,6±37,6** 146,5±33,2 0,047 First request for analgesic (min) 228,7±61,2 207,5±65,3 211,6±54,6 0,369 Group HB: received 15 mg of hyperbaric bupivacaine, Group HR: received 15 mg of hyperbaric ropivacaine, Group HL: received 15 mg of hyperbaric levobupivacaine. *HR longer compared to HB and HL **HR shorter compared to HB and HL Values are represented as mean ±SD or as median[25%-75% percentiles]. 734 Turkiye Klinikleri J Med Sci 2010;30(2)

Anesthesiology and Reanimation TABLE 3: Maximal upper sensory level of the block. Group HB Group HR Group HL Th 3 Th 4 Th 5 Th 6 Th 7 Th 8 Th 9 Th 10 Each symbol (,, ) represents one patient. Group HB: received 15 mg of hyperbaric bupivacaine, Group HR: received 15 mg of hyperbaric ropivacaine, Group HL: received 15 mg of hyperbaric levobupivacaine. Range for maximal upper spread, Th= Thoracic Operatived Side Kazak et al ca i ne, ro pi va ca i ne and bu pi va ca i ne for spi nal anest he si a we re com pa red in pa ti ents un der go ing to tal hip or kne e art hrop lasty. Ro pi va ca i ne and le vo bu pi va ca i ne have been in cre a singly used for spi nal anest he si a, but litt le infor ma ti on is ava i lab le re gar ding the ir use for ma - jor ort ho pe dic sur gery. 13 McDo nald et al. ha ve repor ted that when the do se/ef fect re la ti ons hip of hyper ba ric ro pi va ca i ne and bu pi va ca i ne we re compa red, ro pi va ca i ne ex hi bi ted 50% lo wer po tency than bu pi va ca i ne. 16 Ho we ver, Ca sa ti et al. ha ve recently re por ted that 8 mg of hyper ba ric le vo bu pi - va ca i ne or 12 mg of hyper ba ric ro pi va ca i ne we re ac cep tab le al ter na ti ves to 8 mg of hyper ba ric bu pi - va ca i ne when spi nal anest he si a was li mi ted to the ope ra ti on si de for in gu i nal her ni a re pa ir, but the use of a 1.5 to 1 equ i po tency ra ti o bet we en ro pi va - ca i ne and le vo bu pi va ca i ne re sul ted in a shor ter dura ti on of spi nal anest he si a with ro pi va ca i ne. 6 Si mi lar re sults ha ve al so be en re por ted by Da nel li et al. du ring spi nal anest he si a for Ca e sa re an de li - very. 17 In a re cent study Luck and col le a gu es fo und that hyper ba ric ro pi va ca i ne pro du ced a spi nal block with sen sory block on set cha rac te ris tics si m- i lar to equ i va lent do ses of hyper ba ric bu pi va ca i ne or le vo bu pi va ca i ne, however the mo tor block was less intense. 14 Non-Operatived Side FIGURE 2: Bars represent mean arterial pressures (MAP) after spinal anesthesia for each group. The extended bars represent SD. *Indicates a statistically significant difference between groups (p<0,05). p>0,05 for within groups and group-time interaction FIGURE 1: Median (range) sensory block recorded on both operated and non-operated sides during the first 20 min after spinal injection of 15mg of hyperbaric bupivacaine (Group HB n=30), 15mg of hyperbaric ropivacaine (Group HB n=30) or 15mg of hyperbaric levobupivacaine (Group HL n=30). FIGURE 3: Heart rate (HR) in the three groups were similar during and after the surgery (p>0.05 for between groups, within groups and group-time interaction). Turkiye Klinikleri J Med Sci 2010;30(2) 735

Kazak ve ark. In this study, re la ti vely hig her do ses of lo cal anest he tics we re cho sen when com pa red to mi nor sur gi cal in ter ven ti ons (e.g.; art hros co pi es). Sin ce the du ra ti on of the sur gery in to tal jo int rep la ce - ment is lon ger than art hros co pic kne e sur gery or in gu i nal her ni a re pa ir, mo re musc le re la xa ti on is de si red. Gla ser et al. com pa red ra ce mic so lu ti ons of le vo bu pi va ca i ne (17.5 mg) with bu pi va ca i ne (17.5 mg) in eighty hip rep la ce ment pa ti ents. 18 They fo - und that the num ber of the pa ti ents ex pe ri en cing ad ver se he mody na mic events was con si de rably low in both gro ups (one pa ti ent in le vo bu pi va ca i ne gro - up and two pa ti ents in the bu pi va ca i ne gro up), and conc lu ded that the ef fi cacy of in trat he cal le vo bu - pi va ca i ne was equ al to, but less to xic than ra ce mic bu pi va ca i ne. So far, only one cli ni cal tri al by Fat to ri ni et al. com pa red the ef fects of iso ba ric le vo bu pi va ca i ne (15 mg) and bu pi va ca i ne (15 mg) in 60 pa ti ents under go ing hip and kne e rep la ce ment sur gery. 19 Cha - rac te ris tics of mo tor and sen sory block we re fo und si mi lar alt ho ugh se ve re hypo ten si on was no ted in two el derly pa ti ents (n=2/30) in the bu pi va ca i ne gro up. 19 Up to the aut hors know led ge, this study is the only com pa ra ti ve tri al bet we en the thre e lo - cal anest he tics, le vo bu pi va ca i ne (15 mg), ro pi va ca - i ne (15 mg) and bu pi va ca i ne (15 mg), in the ir hyper ba ric forms and for ma jor ort ho pe dic sur gery. Alt ho ugh re la ti vely high le vels of sen sory block we re ob ta i ned in all gro ups, the in ci den ce of hypo ten si on (30% dec re a se com pa red to ba sal me - a su re ment) was sig ni fi cant only in bu pi va ca i ne gro up (n=14/30) (p= 0.001). Si de ef fect pro fi les of le vo bu pi va ca i ne, ro pi va ca i ne and bu pi va ca i ne were eva lu a ted in a sing le study de sign pre vi o usly. Whi - te si de et al. com pa red the si de ef fects of hyper ba ric bu pi va ca i ne (15 mg) and ro pi va ca i ne (15 mg) in a non- ho mo ge no us pa ti ent po pu la ti on, and re por - ted that hypo ten si on re qu i ring tre at ment was obser ved in 70% (n=14) in bu pi va ca i ne gro up op po sed to in 15% (n=3) in ro pi va ca i ne gro up. 12 In this study, the num ber of the pa ti ents who ex pe ri en ced hypo ten si on re qu i ring vo lu me ex pan ders in gro ups HB, HR and HL we re 14, 3 and 4, res pec ti vely. The most re mar kab le re sult of this study was that the prevalence of hypo ten si on le a ding to he mody na - Anesteziyoloji ve Reanimasyon mic ins ta bi lity and in du ced na u se a and vo mi ting was higher with bu pi va ca i ne. Whi te si de et al. pre vi o usly com pa red the cha - rac te ris tics of 15 mg of ro pi va ca i ne and bu pi va ca - i ne in the ir hyper ba ric forms. 12 The ma in out co me of the study was that hyper ba ric (50 mg ml -1 ) ro pi - va ca i ne pro vi ded re li ab le spi nal anest he si a for shor ter du ra ti on and less hypo ten si on than bu pi - va ca i ne. Event ho ugh the re sults of the cur rent study se ems to be si mi lar; the ma jor dif fe ren ce is the presence and com pa ri son with the le vo bu pi va - ca i ne gro up. Qu es ti ons may ri se for the do sa ge used in this study as dif fe rent do ses of the se lo cal anest he tics we re used in re cent stu di es. The ma in re a - sons were the need for mo re musc le relaxation, and the lack of pre vi o us stu di es with the hyper ba ric forms of the se lo cal anest he tics in ma jor ort ho pe dic sur gery. The re cent study in vol ving the pa ti ents un der go ing elec ti ve Ca e sa re an sec ti on de li very reve als that bu pi va ca i ne is more potent than le vo bu - pi va ca i ne and ro pi va ca i ne. 17 On the ot her hand, the aut hors be li e ve that the anest he si a re qu i re ments and the de si red mo tor block cha rac te ris tics of the ma jor ort ho pe dic sur gery is truly di ver se com pa - red to Ca e sa re an sec ti on. That is why the re sults of this re cent study can not be in ter pre ted for dif fe rent types of sur gery. Ho we ver, furt her stu di es are ne e ded to eva lu a te the cli ni cal ef fi cacy of equ i po tent do ses of the se lo - cal anest he tics when used for spi nal anest he si a in pa ti ents un der go ing ma jor ort ho pe dic sur gery. In this study ade qu a te anest he si a was ob ta i ned with all of the lo cal anest he tics. Ho we ver when the reg res si on ti mes of block to T10 and L1 we re compa red, the lon gest reg res si on ti me was ob ser ved with bu pi va ca i ne fol lo wed by le vo bu pi va ca i ne and ro pi va ca i ne (p<0.01). The ti me to the first anal ge - sic re qu i re ment was shor test with ro pi va ca i ne. However this dif fe ren ce was not sta tis ti cally sig ni - fi cant. When com pa red to bu pi va ca i ne, ro pi va ca i - ne can pro vi de bet ter car di o vas cu lar sta bi lity, but its po tency is low. Le vo bu pi va ca i ne, on the ot her hand, has si mi lar po tency to bu pi va ca i ne and can pro vi de go od car di o vas cu lar sta bi lity com pa rab le to ro pi va ca i ne. 736 Turkiye Klinikleri J Med Sci 2010;30(2)

Anesthesiology and Reanimation CONC LU SION In 15 mg do ses, hyper ba ric le vo bu pi va ca i ne sho - wed si mi lar po tency and block cha rac te ris tics to hyper ba ric bu pi va ca i ne whi le the du ra ti on of mo - tor and sen sory block in hyper ba ric ro pi va ca i ne Kazak et al was the shor test. Le vo bu pi va ca i ne and ro pi va ca i ne had fe wer si de ef fects. With the se fin dings it can be conc lu ded that le vo bu pi va ca i ne at the vo lu me and con cen tra ti on as used in the pre sen ted study can be the pre fer red agent in ma jor ort ho pe dic sur gi cal ca ses. 1. Bard sley H, Grist wo od R, Ba ker H, Wat son N, Nim mo W. A com pa ri son of the car di o vas cu - lar ef fects of le vo bu pi va ca i ne and rac-bu pi va - ca i ne fol lo wing in tra ve no us ad mi nis tra ti on to he althy vo lun te ers. Br J Clin Phar ma col. 1998 Sep;46(3):245-9. 2. Mor ri son SG, Do min gu ez JJ, Fras ca ro lo P, Re - iz S. A com pa ri son of the elec tro car di og rap hic car di o to xic ef fects of ra ce mic bu pi va ca i ne, le v- o bu pi va ca i ne, and ro pi va ca i ne in anest he ti zed swi ne. Anesth Analg 2000; 90(6):1308-14. 3. Hu ang YF, Pryor ME, Mat her LE, Ve e ring BT. Car di o vas cu lar and cen tral ner vo us system effects of in tra ve no us le vo bu pi va ca i ne and bu - pi va ca i ne in she ep. Anesth Analg 1998; 86(4):797-804. 4. Grist wo od RW, Gre a ves JL. Le vo bu pi va ca i - ne: a new sa fer long ac ting lo cal ana est he tic agent. Ex pert Opin In ves tig Drugs 1999; 8(6):861-76. 5. Ma li novsky JM, Char les F, Kick O, Le pa ge JY, Ma lin ge M, Co zi an A, et al. In trat he cal anest - he si a: ro pi va ca i ne ver sus bu pi va ca i ne. Anesth Analg 2000;91(6):1457-60. 6. Ca sa ti A, Mo i zo E, Marc het ti C, Vin ci gu er ra F. A pros pec ti ve, ran do mi zed, do ub le-blind compa ri son of uni la te ral spi nal anest he si a with hyper ba ric bu pi va ca i ne, ro pi va ca i ne, or le vo bu pi va ca i ne for in gu i nal her ni orr haphy. Anesth Analg 2004;99(5):1387-92. 7. Ba der AM, Tsen LC, Ca mann WR, Nep hew E, Dat ta S. Cli ni cal ef fects and ma ter nal and fe - REFERENCES tal plas ma con cen tra ti ons of 0.5% epi du ral le - vo bu pi va ca i ne ver sus bu pi va ca i ne for ce sa - re an de li very. Anest he si o logy 1999;90(6): 1596-601. 8. Cox CR, Chec ketts MR, Mac ken zi e N, Scott NB, Ban nis ter J. Com pa ri son of S(-)-bu pi va - ca i ne with ra ce mic (RS)-bu pi va ca i ne in sup r- ac la vi cu lar brac hi al ple xus block. Br J Ana esth 1998;80(5):594-8. 9. Bay-Ni el sen M, Klars kov B, Bech K, An der sen J, Keh let H. Le vo bu pi va ca i ne vs bu pi va ca i ne as in fil tra ti on ana est he si a in in gu i nal her ni orr - haphy. Br J Ana esth 1999;82(2):280-2. 10. Bre e ba art MB, Ver ca u te ren MP, Hoff mann VL, Ad ri a en sen HA. Uri nary blad der scan ning af ter day-ca se art hros copy un der spi nal ana - est he si a: com pa ri son bet we en li do ca i ne, ro piva ca i ne, and le vo bu pi va ca i ne. Br J Ana esth 2003;90(3):309-13. 11. Cap pel le ri G, Al deg he ri G, Da nel li G, Marc - het ti C, Nuz zi M, Ian nan dre a G, et al. Spi nal anest he si a with hyper ba ric le vo bu pi va ca i ne and ro pi va ca i ne for out pa ti ent kne e art hros - copy: a pros pec ti ve, ran do mi zed, do ub le-blind study. Anesth Analg 2005;101(1):77-82. 12. Whi te si de JB, Bur ke D, Wild smith JA. Compa ri son of ro pi va ca i ne 0.5% (in glu co se 5%) with bu pi va ca i ne 0.5% (in glu co se 8%) for spi - nal ana est he si a for elec ti ve sur gery. Br J Ana - esth 2003;90(3):304-8. 13. McNa me e DA, Parks L, McClel land AM, Scott S, Mil li gan KR, Ahlén K, et al. In trat he cal ro - pi va ca i ne for to tal hip art hrop lasty: do ub leblind com pa ra ti ve study with iso ba ric 7.5 mg ml(-1) and 10 mg ml(-1) so lu ti ons. Br J Ana - esth 2001;87(5):743-7. 14. Luck JF, Fet tes PD, Wild smith JA. Spi nal ana - est he si a for elec ti ve sur gery: a com pa ri son of hyper ba ric so lu ti ons of ra ce mic bu pi va ca i ne, le vo bu pi va ca i ne, and ro pi va ca i ne. Br J Ana - esth 2008;101(5):705-10. 15. Al ley EA, Ko pacz DJ, McDo nald SB, Li u SS. Hyper ba ric spi nal le vo bu pi va ca i ne: a com pa - ri son to ra ce mic bu pi va ca i ne in vo lun te ers. Anesth Analg 2002;94(1):188-93 16. McDo nald SB, Li u SS, Ko pacz DJ, Step hen - son CA. Hyper ba ric spi nal ro pi va ca i ne: a compa ri son to bu pi va ca i ne in vo lun te ers. Anesthe si o logy 1999;90(4):971-7. 17. Da nel li G, Fa nel li G, Ber ti M, Cor ni ni A, La ca - va L, Nuz zi M, et al. Spi nal ro pi va ca i ne or bu - pi va ca i ne for ce sa re an de li very: a pros pec ti ve, ran do mi zed, do ub le-blind com pa ri son. Reg Anesth Pa in Med 2004;29(3):221-6. 18. Gla ser C, Mar ho fer P, Zimp fer G, He inz MT, Sitz wohl C, Kap ral S, et al. Le vo bu pi va ca i ne ver sus ra ce mic bu pi va ca i ne for spi nal anest - he si a. Anesth Analg 2002;94(1):194-8. 19. Fat to ri ni F, Ric ci Z, Roc co A, Ro ma no R, Pasca rel la MA, Pin to G. Le vo bu pi va ca i ne ver sus ra ce mic bu pi va ca i ne for spi nal ana est he si a in ort ho pa e dic ma jor sur gery. [Ar tic le in Eng lish, Ita li an] Mi ner va Anes te si ol 2006;72(7-8):637-44. Turkiye Klinikleri J Med Sci 2010;30(2) 737